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Nutrient deficiencies are widespread among children in India. The government has sought to tackle this by delivering nutrition through meals and supplements at school.

We evaluated the impact on child health of distributing a micronutrient mix to be added to school meals, an iron supplementation programme implemented by school officials, and additional monitoring of school officials.

We found that adding the micronutrient mix to meals had no impact on chidren’s haemogloblin levels, but that haemoglobin levels improved as a result of the iron supplemenation programme.

Additional monitoring of the micronutrient programme had no impact on the programme’s implementation but did lead to improvements in haemoglobin levels. This was likely due to better compliance with the iron supplementation programme.

However, distribution of the micronutrient mix had negative effects on how well the midday meals and iron supplementation programmes were implemented. This was likely because school officials focused on the new programme to the detriment of the existing schemes.

Globally, iron deficiency is a leading cause of anaemia, a condition that is particularly harmful during early childhood, causing fatigue and slower physical and cognitive development with potentially long-lasting effects. The problem is especially acute in India, where 58.4% of children aged 6-59 months are anaemic.

Delivering calories and nutrients through schools is promising because the school system is often the most comprehensive infrastructure available to reach children in remote areas. However, inefficiencies and leakages in the delivery system may limit the impact of the midday meal programme and there is little evidence on the best methods of providing nutritional supplements to children.

In 2001 the Supreme Court of India mandated a school feeding programme known as the ‘midday meal scheme’. In 2012, India’s Ministry of Health and Family Welfare launched the Weekly Iron and Folic Acid (IFA) program, which distributes iron and folic acid tablets to primary and upper primary school children during the midday meal.

This study evaluated the effect of fortifying the school midday meals with a micronutrient mix (MNM) on meal quality and child health in the State of Odisha. In addition, the study varied the intensity of monitoring of school meals to investigate whether and to what extent monitoring improves these outcomes. The three nutrition programmes complement each other: the midday meal provides basic calories while the MNM fortification programme supplies micronutrients that help with the absorption of the iron in the tablets provided by the IFA programme. As the IFA programme ran concurrently, we also tested whether the greater monitoring of the meals had any impact on its implementation.

We found that distributing the MNM increased the presence of micronutrients in meals. There was a high level of take-up of the programme by schools, who added the mix to meals. However it had no effect on haemoglobin levels or other measures of child heath. This is possibly due to the low dosages of MNM used in the programme.

We found suggestive evidence that the government’s IFA supplementation improved haemoglobin, but the impact depends critically on the programme’s implementation. Increased monitoring of school meals improved both meal quality and child haemoglobin levels. High intensity monitoring also improved the implementation of the IFA programme, and more students reported receiving the tablets weekly. Since high intensity monitoring did not improve take-up of the micronutrient mix, it is likely that the improved implementation of the IFA programme explains the improvement in haemoglobin levels among children. Even though the additional monitoring only targeted meals, we found positive effects of the increased monitoring on how well the IFA program was implemented.

The study also found that that the MNM intervention may have negatively impacted the quality of the midday meals and the implementation of the IFA programme. This suggests “crowd-out” in the amount of effort exerted by school officials, who focused their efforts on the new micronutrient fortification programme, and reduced their efforts in implementing the IFA programme.